Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

BPPV (Benign Paroxysmal Positional Vertigo)

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In one line

·Brief spinning spells triggered by head movement, caused by loose calcium crystals floating in the inner ear's balance canals.

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Normal physiology

·Your inner ear holds three semicircular canals—tiny fluid-filled loops arranged at right angles to one another, like a gyroscope—that detect rotation of your head in any direction. At the base of these canals sits a chamber called the utricle, whose floor is covered in gel studded with thousands of tiny calcium carbonate crystals called otoconia (meaning 'ear stones'). Those crystals sense gravity and straight-line movement.

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What goes wrong

·One or more otoconia break free from the gel pad in the utricle and float into a semicircular canal—most often the posterior (back) canal, because it hangs in the lowest position when you lie on your back. Once inside the canal, the loose crystals are heavier than the fluid around them, so every time you tip your head in the canal's plane of movement, they roll and drag extra fluid with them. That abnormal fluid flow pushes the cupula when it should stay still, sending a false 'we are spinning' signal to your brain, even though your head only tilted or turned gently.

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Hallmark signs

·Sudden spinning feeling when you move your head
·Dizziness triggered by rolling over in bed
·A spinning sensation (Vertigo) when looking up or bending down
·Nausea or vomiting during a spinning episode
·Brief episodes that last less than one minute
·Unsteadiness or feeling off-balance between spinning episodes
·Rapid, jerking eye movements during the spinning (nystagmus)
·Sudden hearing loss or ringing in one ear during the a spinning sensation (vertigo)

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Red flags · escalate now

·New severe headache or the worst headache of your life with the a spinning sensation (vertigo)
·Weakness, numbness, or trouble moving one side of your face, arm, or leg
·Double vision, slurred speech, or difficulty swallowing
·A spinning sensation (Vertigo) that lasts hours without stopping or keeps getting worse
·Loss of consciousness, confusion, or trouble staying awake during the spinning episode

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Workup

·Dix-Hallpike maneuver (bedside positional test)
·Supine roll test (bedside positional test for horizontal canal)
·Audiometry (hearing test) if hearing loss, ringing in the ears (tinnitus), or ear fullness is present
·Brain MRI with diffusion-weighted imaging (DWI) if HINTS exam is abnormal or patient has stroke risk factors (age > 50, diabetes, high blood pressure (hypertension), atrial fibrillation (an irregular, quivering heartbeat))
·Orthostatic vital signs (blood pressure and pulse lying, then standing after 1–3 minutes)
·Fingerstick blood glucose if confusion, sweating, or tremor accompanies dizziness
·Serum 25-hydroxyvitamin D level if BPPV recurs often
·Video head-impulse test (vHIT) if the bedside head-impulse test is hard to read or if vestibulopathy is suspected

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Treatment

·Epley maneuver (canalith repositioning) for posterior-canal BPPV — a series of four head positions, each held 30–60 seconds, to roll crystals out of the canal
·BBQ roll (log roll) or Gufoni maneuver for horizontal (lateral) canal BPPV — rolling the patient 360° in steps, or a quick side-lying maneuver
·Vestibular rehabilitation exercises (Brandt-Daroff or Cawthorne-Cooksey home exercises) if maneuvers fail or BPPV keeps coming back
·Meclizine 25 mg by mouth (or dimenhydrinate 50 mg) for nausea during the maneuver or the first 24 hours after
·Vitamin D supplementation (1,000–2,000 IU daily or higher-dose repletion if severely low) if serum 25-OH vitamin D is < 20 ng/mL and BPPV recurs often
·Patient education: sleep semi-upright (two pillows) for 24–48 hours after the maneuver, avoid rapid head movements for a few days, and return if spinning lasts hours or hearing changes
·Surgical posterior canal plugging (rare, < 1% of cases) if BPPV is disabling and fails all maneuvers and rehab for months

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NCLEX trap

·Most BPPV happens because tiny calcium crystals (like little pebbles) break loose inside the inner ear and float into the wrong tube, confusing the balance system. It is not a stroke. The dizziness only happens when the person moves their head in certain ways (like rolling over in bed or looking up), it lasts less than a minute each time, and there are no danger signs like slurred speech, weakness, trouble walking, or new headache. The Dix-Hallpike test (a simple bedside maneuver where you tip the patient's head back and watch their eyes) will trigger the spinning and show a classic jumping eye movement (nystagmus) that proves it is BPPV. Save the brain scan for patients who have those danger signs or whose dizziness does not fit the BPPV pattern.
·Medicine can quiet the nausea for a short time, but it does NOT fix the root cause—the crystals are still in the wrong place. The real cure is a repositioning maneuver (Epley maneuver for the most common type, or Semont if needed). You gently guide the patient's head through a series of positions to roll the crystals back where they belong. It works immediately in most people and often fixes the problem in one session. Teach the patient (or call physical therapy if your facility has vestibular specialists) so the crystals get moved and the spinning stops for good. Skipping this step means the patient keeps suffering needlessly.
·BPPV dizziness is very brief (seconds to under one minute per episode) and only triggered by specific head positions. If dizziness lasts minutes to hours, comes with hearing loss or ringing in the ears, or happens without any head movement, you are probably looking at a different problem—Meniere disease (too much fluid in the inner ear), vestibular neuritis (a virus inflaming the balance nerve), labyrinthitis (infection in the inner ear), or even a central cause like a cerebellar stroke (damage to the back part of the brain that controls balance). Always confirm the pattern first: ask exactly how long each spell lasts, what brings it on, and whether hearing or other symptoms are part of it. Do the Dix-Hallpike test to see the classic short spinning and eye-jump. If the story does not fit, dig deeper before you treat.
·Most patients do feel much better right after the maneuver, but you must give clear follow-up instructions. Tell the patient to keep their head upright (avoid lying flat or bending way forward) for the rest of the day so the crystals settle into place and do not float back. Warn them that mild unsteadiness or a 'swimmy' feeling can linger for a day or two as the brain readjusts—that is normal and not a sign of failure. Explain that BPPV can come back (it recurs in about one-third of people within a year), so if the spinning returns, they should come back for another maneuver rather than just living with it. Also remind them that if new symptoms appear (hearing loss, constant dizziness, headache, weakness), they need to be seen again because that would not be simple BPPV anymore.

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